CQC report explained · a nursing home
What the CQC found at Chandos Lodge Nursing Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found enough staff and kind care, but breaches remained in safe care, recruitment and management.
This was an unannounced focused inspection on 3, 10 and 12 August 2022. Inspectors looked only at Safe and Well-led. They spoke with people, relatives, staff and professionals, and checked care, medicine, recruitment and management records.
People generally said they felt safe. There were enough trained staff, people received prompt help with health concerns, and inspectors saw kind interactions. However, infection control was not good enough. Inspectors found poor cleanliness, unsafe use and disposal of protective equipment, and problems with food storage.
There were also problems with medicine storage and stock checks. Some accidents and safeguarding concerns had not been recorded or reported properly. Recruitment checks were not fully evidenced, and management audits had failed to find several of these problems.
The overall rating was Requires Improvement, as were Safe and Well-led. The provider remained in breach of three regulations and was asked to send an action plan.
Enough staff
Inspectors found sufficient staff to meet people's needs, including at busy times and when one-to-one support was needed.
“Sufficient numbers of staff were deployed to support people.” from the report
People felt safe
People told inspectors they felt safe. Staff used equipment and falls prevention measures to reduce identified risks.
“People told us they felt safe.” from the report
Kind relationships
Inspectors observed positive interactions. Most relatives and people spoke positively about staff being friendly, kind and supportive.
“The staff are wonderful” from the report
Prompt health response
Nursing staff responded promptly when people appeared unwell or needed help. The home worked with health professionals and followed advice.
“I always receive a good handover from the nurse in charge and when I need help there is always a member of staff to support me.” from the report
Choice and least restriction
The report says people were supported to make choices, with decisions made in their best interests when needed.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Infection control
seriousInspectors found poor cleanliness, damaged equipment, unsafe disposal of protective equipment and inconsistent mask use. This was a breach because infection control procedures did not sufficiently reduce risk.
“The service had not fully implemented robust infection prevention and control procedures to effectively mitigate risk to people.” from the report
Medicines storage and stock
seriousTopical creams were not always dated or kept for the correct person. Thickeners were left where people might access them, and stock records did not always match the medicines held.
“We found evidence safe medicine practices were not always promoted in relation to storage and stock management of prescribed medicines.” from the report
Recruitment checks
seriousSome staff files did not show proper references, checks of employment gaps, interview decisions or professional registration. The provider remained in breach of the recruitment regulation.
“Systems were either not in place or robust enough to demonstrate staff recruitment checks were effectively managed.” from the report
Incident and safeguarding records
seriousSome falls, injuries and other incidents were not recorded or reported to the local safeguarding team as required. The report says this limited oversight and delayed possible enquiries.
“The service had failed to report some incidents to the local authority safeguarding adults team as required.” from the report
Weak management oversight
seriousAudits had not found several problems with care plans, incidents, records and confidentiality. Some personal information was visible or left unattended in communal areas.
“Governance systems did not effectively assess, monitor or improve the service to ensure compliance with all required regulations.” from the report
- 01What has been completed to make recruitment checks fully traceable, including references, employment gaps and professional registration?
- 02How are topical creams and thickeners now labelled, stored and checked so they cannot be accessed unsafely?
- 03What changes have been made to bathroom cleaning, protective equipment use and disposal, hand hygiene and food storage?
- 04How are all accidents, injuries and safeguarding concerns now recorded, investigated and reported?
- 05How are audits checked to make sure they identify problems with care plans, incidents and confidential records?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 28 September 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2020
Chandos Lodge Nursing Home was rated Requires Improvement; inspectors found kind care and good clinical support, but gaps in recruitment checks, safety monitoring and activities.
This was an unannounced follow-up inspection on 19 and 26 February 2020. One inspector and an Expert by Experience spoke with people, relatives, staff and a visiting professional. They reviewed care records, medicines records, staff files, incident records and management checks.
The home was rated Good for Effective and Caring. People were treated respectfully, involved in their care and supported with healthcare, medicines, meals and end of life planning. Staff knew people's needs and preferences well.
The home was rated Requires Improvement for Safe, Responsive and Well-led. Recruitment records did not always show that staff were suitable, legionella checks were not fully completed, and activities did not consistently match people's interests. The home's own checks had not found some of these problems.
The overall rating remained Requires Improvement, as it had at the previous inspection. Effective improved from Requires Improvement to Good, and the previous breach about statutory notifications was resolved. However, breaches relating to recruitment and good governance continued.
Kind and respectful care
People and relatives described staff as caring and professional. Inspectors saw people being supported with dignity and respected in their choices.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Medicines
Medicines were stored safely and records showed they were given as prescribed. Covert medicines had been assessed in people's best interests.
“Medicines were stored safely and administered to people as prescribed.” from the report
Care planning
Care plans covered physical and emotional needs, background, preferences, allergies and food choices. Staff showed good knowledge of the people they supported.
“People's needs and preferences were assessed and documented, and staff knew people well.” from the report
Good clinical support
The home made appropriate referrals to healthcare professionals and reviewed changing health needs. A visiting GP was positive about communication with the clinical lead nurse.
“Appropriate referrals were made to healthcare professionals.” from the report
Recruitment checks
seriousSome records did not show that previous employment, gaps in work history, criminal checks or disclosed information had been properly explored before staff started work. This was a continuing breach and created a risk of unsuitable staff being employed.
“We found no evidence that people had been harmed however, systems were either not in place or robust enough to demonstrate staff recruitment checks were effectively managed.” from the report
Legionella safety monitoring
seriousWater temperatures were not checked as required, and actions from a risk assessment had not been followed up. The home acted during the inspection, and later water samples showed no legionella was present.
“However, we found the temperature of the supply and flow of water systems were not checked as required.” from the report
Activities and engagement
needs fixingThe home could not show that activities met individual hobbies and interests. Inspectors saw a group activity that was not inclusive, and staff could give few examples of one-to-one activities for people in their rooms.
“The service could not demonstrate how people's individual hobbies and interests were met to encourage meaningful engagement and interaction.” from the report
Management checks
seriousThe home's quality systems did not identify the recruitment and legionella problems. Some records were incomplete, including induction and fluid monitoring records. This was a continuing breach of good governance.
“The provider's quality assurance systems failed to identify issues with staff recruitment and legionella health and safety checks.” from the report
- 01What checks are now completed before each member of staff starts, including overseas criminal record checks, employment gaps and reasons for leaving previous care work?
- 02How are staffing levels calculated using each person's needs and dependency, rather than only the number of people living at the home?
- 03What legionella checks are now completed, how often are they recorded, and who audits that actions are followed up?
- 04How are activities planned around each person's hobbies, interests and communication needs, including for people who stay in their rooms?
- 05How do managers check that low fluid intake, staff induction records and other incomplete records are identified and acted on?
This was an unannounced follow-up inspection covering all five CQC questions, carried out because the previous inspection found breaches; Safe, Responsive and Well-led remained Requires Improvement, while Effective improved to Good and Caring remained Good. This explanation was written from the published report of 18 April 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Chandos Lodge Nursing Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2016Goodstayed GoodSafe: Requires improvement
- January 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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